Clinical comments on management of urosepsis in a general urological department.

Over a period of 6 years 192 cases of urosepsis have been recorded and managed in our urological department. In almost all cases (97%) the primary focus of infection was the urinary tract and the responsible microorganisms were Gram-negative rods, in order Enterobacter, B. Proteus, E. Coli, Klebsiella and others. Clinical features were dominated by symptoms related to failure or insufficiency of end organs (fever, hypotension, oliguria, mental disorders, respiratory distress etc.). Bacteremia was diagnosed with an incidence of 66%, septic shock 12% and MSOF 20%. Negative bacteriological tests do not rule out the diagnosis of systemic infection. Risk factors are considered advanced age, uremia, diabetes, malnutrition and extensive surgery.

Renal carcinoma with inferior vena cava malignant thrombosis.

During an 11-year period a total of 314 patients underwent surgery for renal carcinoma; 70 had venous extension of the tumour, 31 had extension to the main renal vein and were staged V1 and 39 had involvement of the inferior vena cava and were staged V2. Special attention was paid to the latter group, which was divided into 2 subgroups: V2a for caval extension without ingrowth and V2b for caval extension with infiltration of the caval wall. Thirty-eight patients with caval involvement underwent surgery, with a 13% post-operative mortality rate. Most of the patients with malignant caval ingrowth (V2b) had concomitant lymph node and distant metastases. However, some had negative lymph nodes and no metastases at the time of operation. Perifascial nephrectomy associated with caval tumour removal or lateral subhepatic caval resection for patients staged V2aNOMO significantly increased the survival rate when compared with that of patients with no surgery on the obstructed vena cava. Total resection of the completely obstructed subhepatic vena cava for patients staged V2bNOMO has limited indications but, in selected cases, may prolong survival. This retrospective study supports the reintroduction of indicator V in the TNM staging of renal carcinoma and suggests the splitting of stage V2 into V2a for patients with free-floating caval extension and V2b for caval thrombus with ingrowth and caval wall infiltration.

[Cervicoprostatic section, an endoscopic alternative in treating periurethral adenoma]. / Sectionarea cervico-portstatica, alternativa endoscopica în tratamentul adenomului periuretral.

Uni- and bilateral endoscopic sectioning of the vesical collum and of the prostatic tissue has become an efficient therapeutic alternative for small and middle adenomas and cervicoprostatic scleroses. The authors recommend the use of bilateral cervicoprostatic endoscopic sectioning, with resection of the intermediary tissue (that adds important advantages), harvesting of prostatic tissue for anatomopathologic examination and removal of the remaining tissular isle that might later obstruct the urethra. This original therapeutic method was used in 38 cases (added to 25 patients treated only by uni- or bilateral cervico prostatic section). The good results obtained, without important complications, lasted in time on the dysectatic syndrome, in the patients with cervicoprostatic sclerosis and small and middle adenomas.

[The late results following conservative surgery in transitional cell pyelocaliceal and ureteral carcinomas]. / Rezultate tardive dupa operatii conservatoare pentru carcinoame tranzitionale pielocaliceale si ureterale.

The paper reports on the tardy results following conservative surgeries performed in 15 cases of transitional supravesical carcinomas (8 pyelocaliceal and 7 ureteral). In cases the surgery was necessary (patients with tumours developed on the conservative operation was made deliberately. a unique kidney, in uremia, infiltrative, highly anaplastic), and in 8 patients. Two years after the surgery, 80% of the patients were alive, after 3 years, 66%, after 4 years, 47%, and after 5 years, 33%. The conservative surgeries in the transitional pyelocaliceal carcinomas have deliberate indications for small, unique lesions, T0-T1 N0 M0 G1, technically easily accessible. For the ureteral tumours, the conservative surgeries may be extended to T3 lesions, but with N0 M0, observing the oncologic limits of exeresis in length, that permit the reconstruction of the urinary tract by a rational surgery.

[The treatment of male organic impotence of vascular origin]. / Tratamentul impotentei organice masculine de cauza vasculara.

Two cases are presented, of male sexual impotence of vascular origin. In one case presenting with obstruction of the pudenda artery revascularization of the penis was achieved by anastomosis of the inferior epigastric artery to the deep dorsal vein of the penis. In the second case the insufficient erection was due to a rapid venous drainage of the cavernous bodies, and a venous disjunction was carried out, involving all the superficial veins of the penis and the deep dorsal vein. The results obtained were good. The importance is stressed of the test to papaverin for the differentiation of patients with psychogenic impotence, and the value of the Doppler study for the evaluation of the arterial deficiency of the penis, that should be confirmed by selective angiography. Finally the authors stress the importance of cavernography and of cavernometry for the diagnosis of impotence due to the venous loss.

[Preliminary results in treating superficial bladder tumors by the local instillation of Calmette-Guérin bacilli]. / Rezultate preliminare în tratamentul tumorilor vezicale superficiale cu instilatii locale de bacili Calmette-Guérin.

Post-resection complementary immunotherapy was applied to 55 patients with superficial urinary bladder tumours (Ta, TI) with Calmette-Guérin bacilli (Pasteur strain) prepared by the "Cantacuzino" Institute. The treatment consisted initially in scarification and instillation in 19 patients, and in instillation alone inside the urinary bladder in 43 patients, according to Morales, and respectively Brosman protocols. In 7 patients only Morales immunotherapy was applied initially but after recidive and resection they too were treated according to the Brosman protocol. One should note that most of these tumours were of the recurring type, with multiple recidives in the antecedents in 60% of the patients, and that the surgical treatment, as well as instillation of cytostatic drugs had failed. In the present protocol transurethral resection was carried out in 93% of the cases. After immunotherapy the following aspects were noted: in 75.8% of the patients there were no recidives 25 months in the average after the start of the treatment. In the average 13 months elapsed between the start of the treatment and the occurrence of the first recidive, as compared with 7 months in the average for the controls. Most of the recidives in patients with instillations occurred in those in whom the tumour had gone beyond the basal membrane. In 2 patients with infiltrative recidives total cystectomy was carried out. With regard to degree of anaplasia following BCG instillation there was a down-grading in 43% of the cases. There was no fatality ascribable to BCG treatment in our series, and both general and local complications were insignificant considering the therapeutic benefit.

[Urography and the isotopic renogram under diuresis enhance the diagnosis and the indication for therapy in congenital hydronephrosis]. / Contributia urografiei si renogramei izotopice sub diureza crescuta la diagnosticul si indicatia terapeutica a hidronefrozelor congenitale.

Analysis of a group of 276 patients with congenital hydronephrosis by dysfunction of pyeloureteral function shows that in the most cases the diagnosis has to be established by corroborating the data given by urography, echography, and isotopic renogram. In the cases of controversial hydronephrosis diagnostic, urography and renogram under diuresis induction are very important in practice.

[Endoscopic resection of an orthotopic ureterocele, an alternative to open surgery]. / Rezectia endoscopica a ureterocelului ortotopic, alternativa pentru chirurgia deschisa.

The paper reports on the results of the endoscopic treatment in 16 cases of orthotopic ureterocele, out of which 11 developed on a simplex ureter and 5 on the superior ureter of the pyeloureteral duplicity (ren duplex). In 6 patients the pseudocystic dilatation of the submucous ureter contained calculi. The endoscopic treatment consisted of: the ureterocele resection in 12 patients (in 6 of them it was associated with the extraction of the calculi with Lowsley's lithotryptic clip): the ureterocele incision in 3 cases; and the endoscopic resection of the intravesical sac, with nephrouretectomy of the dysfunctional pelvis and the respective ureter in one case. The results recorded showed urographic improvement in 14 patients and uroculture sterilization in 11 cases of 14 with postsurgical urinary infections. Only in one case, the ureterohydronephrosis advanced, requiring the subsequent ureter-bladder reimplantation. No case of bladder-ureter reflux following the endoscopic resection or incision of the orthotopic ureterocele was recorded. Endoscopic resection or incision is a simple and efficient method for treating small or middle orthotopic ureteroceles, if the superior urinary system is recoverable. The method is simple and with low risks, and it can be applied as first therapeutic time in all the cases, even in those in which the chance of the definitive solution is less probable, as in the secondary surgical time the classical surgical correction of the uretero-bladder junction can be used.

[Total cystectomy in the treatment of infiltrative bladder tumors. The conclusions of an analysis of postoperative results in a series of 269 nonselected patients at late follow-up]. / Cistectomia totala în tratamentul tumorilor vezicale infiltrative. Concluzii rezultînd din analiza rezultatelor postoperatorii într-o serie neselectionata de 269 de bolnavi revazuti tardiv.

The authors report their experience with 341 radical cystectomies, and 61 anterior pelvectomies for infiltrating urinary bladder tumours, of which 269 were followed at long periods of time after surgery. In 56% of the patients there was tumoural involvement of lymph nodes at the time when cystectomy was performed. In 88% of the cases the tumours were of G3 stage. Fifty-one percent of the patients had had one previous surgical procedure, and in 75% of the cases surgery was performed when the upper urinary apparatus was already dilated by tumoural obstruction, or when high serum nitrogen was present. Planned radical cystectomy was possible in only 26% of the patients. The technical procedure implies a significant change consisting in the exclusive use of the urethropelvic drainage, and this had excellent results. The urinary derivation used was adapted to the stage of development of the tumour, and after consideration of the condition of the upper urinary apparatus. In 130 cases cutaneous urethrostomy was performed, in 95 patients urethrocolic derivation, in 23 cases cutaneous transurethral ureterostomy, and in 6 patients substitution bladder was achieved. The global postoperative mortality of 16.6% was mainly due to the advanced age of patients, the advanced stages of the tumours, to high serum nitrogen, infections, and to operatory indications that were not always justified but were determined by clinical complications and the extreme discomfort of patients. The most frequent early postoperative complications included an association of toxic shock and high serum nitrogen. In the authors' experience preoperative radiotherapy did not have satisfactory results, and chemotherapy only resulted in inconstant improvement of the patients' condition The late results were not satisfactory, the deaths in the first two years after surgery being the result, almost in exclusivity, to a continued evolution of the neoplastic tissue remaining in the pelvic cavity, and that was due to the fact that the patients had been operated at a very advanced stage of the disease. Total cystectomy has an elective indication in urinary bladder tumours of the T2, T2a, or T3b type, with N0 and M0. It should be carried out as planned surgical intervention and presumes a mandatory urinary derivation that should provide a maximal renal protection.

[Endoscopic resection in the treatment of infiltrative bladder tumors. The analysis of a nonselected group of 111 cases]. / Rezectia endoscopica în tratamentul tumorilor vezicale infiltrative. Analiza unui lot neselectionat de 111 cazuri.

A total of 111 nonselected cases are presented, of infiltrative urinary bladder tumours, in which endoscopic resections were performed. In most of the cases (83% of the patients) the tumours were of the transitional carcinoma type, the transurethral intervention having been planned in advance. In 35% of the cases resection was done by necessity, and in 3% of the patients resection was done as an emergency for hemostatic purposes. Haemorrhage was the most frequent of the surgical complications, and was reported in 5 patients. Renal failure was the most frequent of the medical complications. In 50 patients radiation therapy was carried out following surgery. The late results are as follows; 44% survivals at 2 years, 14% survival at 3 years, and 9% survivals at 9 years.

[Diagnostic, staging and therapeutic problems in invasion of the abdominal vena cava in renal cancer]. / Unele probleme diagnostice, de stadiere si terapeutice ale invaziei venei cave abdominale în cancerul renal.

Between 1976 and 1987 the authors have operated 351 renal carcinomas of the clear cell type, and 51 Wilms tumours. In 35 of the patients there was malignant thrombosis of the abdominal vena cava. Total resection of the vena cava was done in the subhepatic portion in 6 of the patients, and lateral resection with removal of the thrombus was carried out in another 15 patients. In the other 14 cases thrombosis of the vena cava was accompanied by visceral, lymph node metastases, or by invasion of the surrounding organs, and palliative nephrectomy alone was done in 13 patients. One of the patients declined surgery. A new staging is suggested, of the venous invasion, which correlates satisfactorily with the patients' perspectives. Invasion of the main renal venous pathway is noted by V1, invasion of the abdominal vena cava is noted by V2 (with subgroups V2a, when the thrombus is free in the vein, without contacts with the venous wall, and V2b, when the thrombus infiltrates the wall of the vena cava. In cases staged as N0M0V2a perifascial nephrectomy and unblocking of the abdominal vena cava may achieve remarkably long survival, while the V2b substage should be assimilated to visceral metastases.

A new transperitoneal approach for retroperitoneal lymphadenectomy.

A new transperitoneal approach for retroperitoneal lymphadenectomy is presented. The abdominal incision resembles the letter omega, gives free access to both suprahilar renal areas and abdominal pelvis and provides solid repair of the abdominal wall. It may also be used for surgery on both kidneys and adrenals.